Were the budgetary reforms to the Better Access to Mental Health Care initiative appropriate? — Yes

YES The federal Budget provides $2.2 billion for mental health care over the next 5 years. From our point of view, this budgetary provision is doubly positive because we feared the Australian Government’s Better Access to Mental Health Care initiative would be axed or irrevocably altered to fund other necessary mental health services. Better Access enables consumers to receive a specified number of Medicare-reimbursable sessions of mental health care from an allied health professional (on referral from a general practitioner who completes a Mental Health Care Treatment Plan), or from a GP directly. The Budget has modified the Better Access rules to achieve savings that are not insignificant ($580 million over 5 years), but its integrity has largely been retained.

We conducted an evaluation of Better Access which drew on 20 different data sources, including Medicare data and a study of outcomes for nearly 900 consumers who received care from psychologists and GPs, funded under the Better Access initiative.1 Our evaluation highlighted a number of positives. Better Access delivered over 11 million services to over two million people between 2007 and 2009. Typically, these services involved evidence-based treatments like cognitive behavioural therapy. Half of all Better Access users had not received mental health care before, and over 90% had diagnoses of depression and/or anxiety. The vast majority of those who used Better Access services had positive outcomes, with most shifting from high or very high levels of psychological distress before treatment to much more moderate levels after treatment. Although Better Access has cost the Australian Government more than originally anticipated ($1.45 billion from its introduction in November 2006 to June 2010, which is about 2.5 times more than originally anticipated), it appears to provide good value for money. The above positive outcomes were achieved at an average cost of about $750 per episode; this compares favourably with previous estimates of about $1100 for the optimal treatment for anxiety and depression.2

The first of two Budget-related changes to Better Access is a reduction in the permissible number of sessions with allied health professionals. Previously, consumers were entitled to an initial six sessions of care, with the option of an additional six after review by the referring medical practitioner (and a further six in exceptional circumstances). Under the new rules, the number of additional sessions will be capped at four, bringing the total to 10 and saving an estimated $174.6 million. The evidence from our evaluation suggests that this will not affect large numbers of consumers; we found that 75% of consumers received 1–6 sessions, 20% received 7–12, and 5% received 13–18.1 The new arrangements therefore seem reasonable, but ongoing evaluation will be needed to ensure that consumers with complex conditions are not disadvantaged.

The second Budget-related change to Better Access is the creation of a two-tier rebate for GP Mental Health Care Plans ($126.43 or $99.55 for a session of 40 minutes or longer, depending on whether GPs have completed a basic 6-hour training course; $85.92 or $67.65 for a session of 20–40 minutes). The existing rebate for the Mental Health Care Plan, irrespective of the duration of the session, is $163.35 for GPs who have completed training and $128.20 for GPs who haven’t; the anticipated saving from this change is $405.6 million. The rationale for this change comes not from our evaluation but from analysis of the Bettering the Evaluation and Care of Health (BEACH) data,3 which indicated that over 80% of Mental Health Care Plans were being completed in under 40 minutes. In our evaluation, GPs and allied health professionals had mixed views about the value of Mental Health Care Plans. Some allied health professionals felt that they were a useful means of improving collaborative care, as did some GPs. Other allied health professionals and GPs were less sanguine, but for different reasons. Some allied health professionals claimed that the information they received from GPs was often insufficient and others expressed resentment that the GP’s rebate for the Mental Health Care Plan was frequently more than what allied health professionals received for providing an individual session of care (between $50.95 and $140.15, depending on the type of provider and the length of the session). Some GPs were critical of the training requirements to receive the higher rebate; they felt that their referral went into a “black hole” and that ongoing communication with the allied health professional was limited. It seems reasonable to provide a time-dependent rebate which is commensurate with the time spent in preparing the Mental Health Care Plan, although it will be necessary to monitor the effect this change has on the likelihood that GPs will prepare Mental Health Care Plans.

Better Access is part of a suite of mental health care reforms that received attention in the Budget. Many of the others complement Better Access by reaching groups that may not be best served by a fee-for-service approach. We believe the Budget reforms have struck an appropriate balance between retaining the core features of a program that appears to be working well while at the same time providing additional resources for important existing and new initiatives.